Professional Evaluation Group Of Florida, Inc.

Please fill out IME / PEER REVIEW FORM below and click on Submit button for a quick response.

For helpful hints on how to use IME / PEER REVIEW FORM below click on Help.

For your convenience we have also provided a Word Version of the IME/PEER REVIEW form below.

IME PEER /RECORD REVIEW DIAGNOSTIC/RADIOLOGY REVIEW
Company:		Date:
Address:		Claim #:
Adjuster:		Insured:
Phone #, ext.:		Date of Accident:
Adjuster E-Mail:
Claimant:		Attorney:
Address:		Address:
City/State/Zip:		City/State/Zip:
Telephone Home:		Telephone:
Work :		Fax #:
Date of Birth:
Social Security #:
Case Type :
Specialist Request For IME:
Other: Medical Records: Mailed None Available To Be Picked Up
Treating Physician:
Name:
Address : City/ State/Zip:
Phone #:
Ancillary Test: CAT SCAN EMG X-RAY OTHER :
Area of Concern: Max. Medical Improvement Causal relationship to date of loss Ability to Return to Work Need for Further Treatment Need for Surgery	Activity Restrictions, if Any Permanency Degree of Disability Other:
Special Instructions:

Carrier:
Report to the attention of: Telephone #, : ext #:

Type the following:

To print a copy for your file, prior to submitting, use the browser File/Print option and then click submit.

You can either download the Word Document and fax it to us at (954) 721-4993 or you can fill out the form online and e-mail directly to us.

For further assistance on using the Word version of the IME Form please follow instructions below:

1. Double click on the Word Icon and select open.

2. Type in the appropriate information and then attach the completed form to your e-mail. pegime@aol.com

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